This is a continuation of Dr. David Pate’s article on population health. See page one here.
Precursors and the Future
Population health management has emerged with hope and promise to improve health care and lower healthcare costs.
First, let’s look at precursors and the role they play in the future of population health management.
There are many versions of patient-centered medical homes (PCMHs) and Accountable Care Organizations (ACOs) serving different populations in variously structured reimbursement methodologies.
Some have not been successful, some have been successful in some areas and not others, and a few have been very successful. Following are broad, general observations that may not be true of all PCMHs and ACOs.
PCMHs and ACOs are models largely focused on care coordination, the third bucket of cost savings opportunity I wrote about last week.
Generally, PCMHs and ACOs are paid on a fee-for-service basis, but in the case of the PCMH, may receive an additional payment for those higher-cost patients, and in the case of the ACO, may receive a pay-for-performance award or shared savings based upon meeting certain quality measures and achieving certain cost reduction goals.
Their success is often measured in terms of decrease in emergency room visits and avoidable readmissions. These areas of focus make sense, as we saw in part 2 how those patients are older, chronically ill, and have socio-economic and mental/behavioral health issues that make their care disproportionately costly.
At the same time, PCMHs and ACOs still are enhanced fee-for-service approaches to the treatment of patients. That means they are unlikely to be successful in improving either of the other two big buckets of healthcare costs and spending without transformation of the business model and the care model.
That transformed business model must pay a provider-based organization or ACO a per-member, per-month fee to provide health education, health screenings, preventive care, risk factor mitigation initiatives and strategies, and wellness promotion in order to impact bucket number 1, and a fixed payment (capitation payment, percent of premium, or other fixed budget arrangement) to reverse the incentives of fee-for-service that reward the provision of low-value/no-value services I referenced in bucket number 2.
This probably sounds a lot like the HMOs of the ‘80s and ‘90s and next week, I will explain why I think things are different now.
Transformation in the payment model will enable healthcare organizations to provide a system of care to a population. That said, this approach to population health must account for subpopulations.
Not Your Father’s HMO
I discussed the necessary transformation of the business model to support population health and lower U.S. healthcare costs: a transition from pay for volume (fee-for-service) to pay for value.
To promote the investment of the necessary time, energy, and resources into improving the health of people who are not yet patients, some kind of per-member, per-month payment would be necessary. This would perhaps be analogous to a gym membership.
Further, if we are to also address the second-bucket costs that I have previously referenced in this series, namely the provision of low-value/no-value services, we must address the incentives in the current reimbursement system that promote the use of these services.
It seems to me that the most effective way to structure a workable model is to provide capitation or a percent of premium payments that move health care toward evidence-based medicine and away from inefficiencies.
You may ask, “What is the difference between what I am proposing and the HMOs of the ‘80s and ‘90s?”
My response, and I will deal in generalities since there certainly are exceptions, is that the HMOs, other than a few provider-based HMOs, were driven by insurance companies. I see PCMHs, ACOs, and the integrated delivery networks necessary to truly deliver on the promise of population health to be provider-led. That’s a big difference.
In addition, whereas the focus previously was on just the cost, today’s population health managers must truly embrace better health, better care, and lower costs. To these ends, providers should not be rewarded for decreased costs unless they first can satisfy certain quality and safety measures.
In fact, the financial rewards should consider both quality improvements as well as cost savings, but quality measures must be the threshold for cost savings rewards.
In the ‘80s and ‘90s, though some providers were capitated, most weren’t. Most were paid on a fee-for-service basis, but in a self-defeating model, in which the provider took steep discounts that encouraged the provision of more services while the insurer attempted to control services through denials. Ideally, the population health managers of the future should hold the performance risk and handle utilization internally.
And though HMO stood for “health maintenance organization,” the focus was disproportionately on sick care, rather than promoting the health of a population. Unfortunately, people changed their health plans often enough that it didn’t make sense for most of these organizations to spend a lot on health, when they were unlikely to see the return on that investment.
And finally, the early models relied on a primary care gatekeeper system. While it is my belief, as a primary care physician myself, that most everyone should be cared for by a primary care physician, there are many conditions that demand early attention by a specialist and other conditions that are better cared for by a specialist. The model needs to be one in which the primary care physician is coordinating care but should not be an impediment to prompt attention by a specialist when needed.
The future entails specialists supporting many primary care providers by tele-consults with the patient in the primary care physician’s office, with electronic access to the complete medical record and tests, and a real-time assessment of the patient to determine in those tough or uncertain cases whether the primary care physician should initiate treatment and follow-up or whether referral is cost-effective.
Keys to the success of population health that often were not employed fully in the early models of care are patient-centeredness (the patient needs to be at the center of the decision-making process and providers need to assess and take into consideration the patient’s treatment goals), an integrated electronic health record which the patient and all care providers have access to, seamless care without the need for the patient to re-register and fill out a separate health history for each visit, an emphasis on quality and safety measures and performance, provider accountability for the outcomes of care and the costs of that care, and a focus on health.
It’s About the Subpopulations
We will not succeed in reducing healthcare costs until we can promote the health of people who are not yet patients, better care for people who are patients, and better coordinate the care of those who consume the highest proportion of the healthcare spending – the chronically ill.
There is no one-size-fits-all approach to population health management, but we must first identify all who are in that population. If, for example, the population is the participants in your employee health plan, it is critical to realize that spouses and children are likely in that population. After passage of the Patient Protection and Affordable Care Act, now adult children are likely beneficiaries of your plan. So, it would be very possible that employees are the minority of people covered under your employee health plan.
Once you identify those in the population for which you are accountable for the quality of outcomes and cost of care, you will want to segment this population into subpopulations.
Here are the minimum sets of subpopulations I believe you would want to identify:
- Those who are currently healthy and apt to stay that way, i.e., they have healthy behaviors and they have no identified family or genetic risk factors. This population needs the fewest resources from your organization. They need access to health information; a point of contact for healthcare, nutritional, and exercise questions; periodic health screenings and health maintenance; and reminders as to when they need to obtain these screenings and preventive services. Since a lot of this population will be children and young adults, you would want to consider mobile applications and other fun ways, that are convenient for them, to keep in touch with this group.
- Those who are currently healthy and have risk factors that place them at risk of becoming patients. This is a population with significant opportunity – keeping people from becoming patients. Risk factors may include, among other things, obesity, smoking, e-cigarette use, illicit drug use, prescription medication abuse, alcohol abuse, risky behaviors (e.g., not using seatbelts, keeping guns in the home that are not secured, or having unprotected sex with multiple partners), family history and genetic risks, and depression. In this population, it is important that you identify the risks and discuss them with the person; identify the person’s readiness for change, willingness to change, and establish their personal goals; and then offer resources for risk mitigation.
- The acute care subpopulation. People will move into and out of this subpopulation. The keys here are to make access to care timely, provide the patient with evidence-based care (in those cases for which we have evidence to guide our treatment), and ensure our programs and services are designed to deliver the highest possible outcomes, in the safest manner possible, at the lowest possible cost.
- The chronically ill subpopulation. This group provides us with the greatest immediate opportunity. The ability to effectively coordinate care and manage care transitions can reduce emergency room visits, increase medication compliance, reduce avoidable hospital readmissions, and decrease duplication of tests and risks of medication interactions. Further, there are additional cost savings if population health managers focus not just on the acute care settings, but create post-acute care management programs.
Anthony and Barbara
Anthony is a 24-year-old man who is healthy and has no known medical risk factors. He signed up with an insurance plan for which your health system takes risk. He has selected a physician and, right after his check-up, downloaded an app through which he can log in to email his physician, check lab results, and schedule visits online.
He filled out a health risk assessment form that showed him his “vitality” score and allows him to monitor his health status. He got information about diet, exercise, and health behaviors.
After his check-up, his doctor wanted him to have a fasting blood sugar and cholesterol blood test. Logging into his online account, he noted the appointment made for the lab tests.
Anthony returned to work after the tests and received an email that indicated his lab results were ready. He logged into his online medical record, clicked “test results,” and received the results and a note from his physician indicating that his tests were normal.
A couple of months later, Anthony developed sneezing, itching eyes, and a runny nose. Not experiencing relief with over-the-counter medications, he sent an email to his physician explaining his symptoms. Within two hours, Anthony received an email from his physician’s assistant, letting him know that a prescription was sent electronically to his pharmacy and explaining that he should contact them for an online video visit if he was not better in a few days.
In the fall, Anthony received an email reminder to get a flu shot.
Barbara is a 24-year-old woman who is overweight and smokes, is not physically fit, and has a family history of diabetes, hypertension, and heart disease. She works for a company that has chosen your health system to manage their employee wellness program.
Barbara took a health risk assessment online. Her vitality score indicated that her health was suboptimal and that she was at high risk for heart disease, stroke, and cancer because of her smoking history, her weight, and her level of physical activity. Wellness team members then visited her workplace and conducted health screenings. Her BMI, blood pressure, blood sugar, and cholesterol were checked.
Barbara told her health coach that she had wanted to stop smoking and lose weight, but didn’t know how and feared stopping smoking would aggravate her weight problem. With the help and support of her coach, she started a smoking cessation program and a journey toward improved wellness. A nutritionist took her and others beginning the same journey to the grocery store and taught her how to read labels and make healthy choices.
With continued direction from the health coach, Barbara began using a pedometer and started a daily walking program with friends. She checked in with her health coach every week and received new ideas and encouragement. She attended cooking classes and started exercising.
Now Barbara is a non-smoker. She’s losing weight, and feels stronger and fitter than ever!
Carlos is a 57-year-old man experiencing a stroke. He was at work when he noticed that his hand was weak and he couldn’t pick up his coffee cup. A colleague remarked that his speech was slurred.
His colleague called 911 and Carlos was taken to one of your health system’s emergency rooms. The ER team had already been notified and was ready for Carlos’ arrival. He was whisked into a room where a quick assessment was performed.
A nurse hit the “e-ICU” button on the wall. A camera came on and a stroke neurologist from another location in your system appeared on the monitor. The stroke neurologist could watch the ER physician conducting the neurologic exam.
The medical team quickly moved Carlos to radiology for a scan. The images were visible to the neurologist online and a diagnosis of stroke was made.
It was determined that Carlos was an excellent candidate for clot-busting drugs and the medication was administered. And whereas before, an air ambulance would have been dispatched to pick up Carlos and fly him for further treatment, the remote monitoring means that Carlos is able to remain in the hospital close to home and his family, saving significant expense.
Carlos recovers well from his stroke and is able to be discharged home with a treatment plan of physical therapy, speech therapy, occupational therapy, and a nurse care coordinator. Once he returned to work, Carlos’ nurse practitioner monitored his weight, blood pressure, and fitness to ensure that he would be at minimal risk for another stroke.
Carlos’ capitated health plan means he can pay a monthly premium without additional charges for his hospital stay, scans, blood tests, therapy, and follow-up visits. He receives regular messages from your health system about vaccinations and screening tests following his stroke. A daily medication alarm reminds him to take his aspirin and other medications.
Doris is a 63-year-old widow with heart failure, diabetes, and kidney dysfunction. She has a primary care physician who has been treating her diabetes, a cardiologist for the heart failure she developed two years ago, and a nephrologist because her kidneys are failing.
She has a long history of diabetes. In the past, Doris’ diabetes was not well controlled. She did not feel that she understood her diet or medications and at times, skipped her medications. Several times, Doris was discharged from the hospital only to be readmitted within a week or two when her diabetes got out of control or she developed another complication. She racked up significant medical expenses due to the hospitalizations and the many physicians involved in her care.
Now, her team of physicians from your health system has access to all of her medical records, and they are kept up-to-date with her current medications and recent lab tests. All of her physicians are on the same electronic health record, so they all have access to the same information in a timely way.
Doris’ daughter lives out of town. She worries about her mom, but is able to log into the medical record as a proxy and see all of her mother’s test results. She also can email her mother’s doctors with any questions.
Doris now participates in a care coordination program. She enjoys the classes about how to live with diabetes, the importance of her diet, and medications. She has a glucometer that measures her blood sugars and transmits the results electronically to her physician’s office. If her blood sugar is out of whack, she receives a phone call with instructions from her doctor or physician’s assistant. She hasn’t had to return to the hospital for her diabetes, and her daughter is very relieved.
Every other month, Doris visits the heart failure clinic, where a heart failure specialist and a team of professionals help make sure that her medications are adjusted properly. The electronic health record provides all of her caregivers with alerts about possible medication interactions and other information.
In between visits to the heart failure clinic, a nurse coordinator visits Doris at home to ensure that her questions are answered, her living situation is safe, she is taking her medications as prescribed, and she is keeping her appointments. Doris checks her weight and the nurse coordinator monitors her readings as they are transmitted electronically from Doris’ bathroom scale. She gets calls from the nurse to see how she is feeling and instructions from the heart failure clinic regarding any medication adjustment.
Doris is also attending cardiac rehabilitation. An exercise physiologist has worked with Doris to design an exercise program that is helping her feel stronger while not overly stressing her heart. The program has even helped her better control her diabetes.
While Doris’ daughter was in town visiting, the palliative care nurse and doctor visited to see if there was anything they could do to help with any shortness of breath or other symptoms. They discussed whether Doris would want dialysis if her kidneys stopped functioning. They also talked about what Doris would want if her condition deteriorated, she ended up in the hospital, and faced the possibility of CPR or a breathing machine.
Decisions agreed to meant that Doris’ daughter would not have to make the decision if Doris was unable to or her daughter could not be reached. Doris and her daughter were grateful and relieved to be having this discussion. And in the meantime, Doris feels better and stronger than she has in years.
David C. Pate, M.D., J.D., has been president and CEO of St. Luke’s Health System, based in Boise, Idaho, since 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center. Read his blog at http://drpate.stlukesblogs.org/